Provider Demographics
NPI:1720106743
Name:JASPER, KENDALL (PHD)
Entity Type:Individual
Prefix:
First Name:KENDALL
Middle Name:
Last Name:JASPER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 W MOREHEAD ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-1521
Mailing Address - Country:US
Mailing Address - Phone:980-819-5692
Mailing Address - Fax:980-819-5694
Practice Address - Street 1:223 W MOREHEAD ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28202-1521
Practice Address - Country:US
Practice Address - Phone:980-819-5692
Practice Address - Fax:980-819-5694
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4088103TC0700X, 103TC2200X, 103TB0200X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6107205Medicaid